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Cervical Stenosis after Menopause
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An_205921 posted:
I can find almost no info about developing cervical stenosis (the closing off of the opening to the cervix) after menopause. I went today for a repeat pap test and again the doctor could not get the instument into the cervical opening. The doctor had me insert Misoprostol tablets to no avail. My cervix is totally closed. This is a new situation. I am 58 and have been in menopause for about four years. No problems until now. My doctor says I am the 4th woman in the past six months to have developed this post menopause. The very little info I found says if previous pap tests have been normal then nothing is to be done. But I also read that chances for cervical cancer increase with age so doing nothing seems foolish. Can anyone give me any information? I am confused and worried.
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Mary Jane Minkin, MD responded:
Dear Anon,
Sorry I haven't commented on your question earlier (peri-Thanksgiving busy!) It is quite true that many women's cervices narrow after menopause. However, in general, we don't usually worry women with keeping them dilated, unless we need to get into the cervix and the uterus (like if someone developed bleeding which we needed to evaluate). It does not seem that we miss any cancers-as long as women go for regular exams, and inspections of their cervix.
So what do we do if we need to get in there? we can use vaginal estrogens for a few weeks-that in general will soften the tissue up. And the misoprostol tablets can be of assistance, too. Occasionally, I have had to take a patient to the operating room to give her anesthesia and make her comfortable so that I can get in there. But not to worry, starting with very tiny cervical stretchers call cervical dilators, and with some anesthesia, we can get in there if we need to almost all the time.
Bottom line: don't worry about the cervical stenosis. Continue to see your doc for regular check ups-and let him or her check the cervix at the regular exam. And do report any bleeding.
Happy Thanksgiving,
Mary Jane
 
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leanfox replied to Mary Jane Minkin, MD's response:
I am in this same situation. I am 59, my cervix is closed and my Doctor wanted to perform a hysteroscopy and d&c to see if a polyp is causing my bleeding. She was unable to open the cervix to enter the uterus to see if I do have a polyp. What would be the next course of action? She mentioned getting a second opinion or possible hysterectomy. I had not heard of vaginal estrogens, but would be open to the least invasive treatment.
 
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Mary Jane Minkin, MD replied to leanfox's response:
Dear leanfox,
This problem of cervical stenosis is a lot more common than most physicians realize. I've actually had women, perimenopausally, develop severe pain-because they were bleeding, and the cervix was shut so tight, it couldn't escape-and I had to stretch the cervix with dilators. I would suggest to your doc that she try to use some vaginal estrogens with you for a month or so, and to consider asking you to take some misoprostol for a couple of days before she tries to dilate your cervix again-it well might work.
Have you had an transvaginal ultrasound of your uterus? if it does show some abnormalities, and she absolutely cannot get into your cervix, I would suggest getting a second opinion-perhaps from a gynecological oncologist (not because I think you have cancer, but because they deal with "tricky cervixes"-)but see if she'll try you with some vaginal estrogens and some misoprostol in advance,
Good luck,
Mary Jane
 
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1222pink replied to Mary Jane Minkin, MD's response:
I am 51 and thought I was going through regular menopause. I had random periods for two years. When I had one it was heavy. In may I had one extremely heavy period but no pain. My gynecologist did a vaginal ultrasound and found that the wall was thickening again...two weeks later I had another period but it was not nearly as heavy...just painful. He decided to do a biopsy to be safe but could not because my cervix was nearly closed. He then scheduled to put me to sleep and try to dilate the cervix to get the biopsy and do a D and C. He again was unable to get through the cervix and punctured a hole in the wall. I have now been referred to an oncologist gynecologist who wAnts to do a robotic hysterectomy. I am bloated, uncomfortable, suffering with backaches and cramping...none of which I had before. I am making myself sick worrying about what is going on.
 
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Anon_6061 replied to 1222pink's response:
Hopefully, Dr. Minkin's responses to the original poster are helpful. And she may came along to address your situation.

I'm going to respond based on my experience and research after having had an unnecessary hysterectomy that I deeply regret. Based on your menstrual history, it sounds like you're in perimenopause. I didn't get the impression that you've ever gone at least 12 months without a period. Perimenopause is a time when cycles can be very irregular with erratic and oftentimes heavy bleeding. The endometrium can get quite thick at times during this transition but usually reverts back to normal on its own.

I've read that the ultrasound should be done 1 or 2 days after your period ends when the lining is its thinnest. According to medical literature, polyps (which can cause heavy bleeding) can be difficult to differentiate from the lining on u/s giving the appearance of a thicker lining.

Endometrial hyperplasia (no proof that you even have this) that occurs during perimenopause oftentimes reverts to normal on its own. But if it doesn't, progestins (such as Provera or Megace) are usually effective. So since you're not even sure you have hyperplasia and IF YOU DID, a hysterectomy sounds extreme since meds would likely treat it. When getting a second opinion, I've read that it's best to go to a different "network" of doctors.
 
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some_inquiz replied to Anon_6061's response:
I am 52 years old. In 2006 I was put into medical menopause with tamoxifen, then a post menopausal med which did not work because my hormones had returned to pre-menopause status. This was all after having estrogen receptive breast cancer. Then i was given depo shots every month for 4 months until the symptoms were so bad i could not stand it any longer. I think i had one or two more periods after that, with the last one occurring a couple of years ago. I was45 at the time of breast cancer. I have recently been having lower abdominal pain, bloating, and have a prolapsed uterus and bladder. They did a urinary study and a trans-vaginal ultrasound, which showed a thickening of the endometrium and a couple of uterine polyps. I also had surgery for removal of several uterine polyps in 2000. I have also previously had a LEEP procedure, at age 32, and two cryotherapies in my 20's of the cervix, along with lazer surgery for endometriosis in my late 20's. I went in for a biopsy of the endometrium today since it is enlarged, but we had to skip the biopsy because the cervix is closed. I was told i can wait a few months for surgery, which will include removal of the uterus and cervix at which time they will do a biopsy since it was not possible today. Should i have any concerns about the polyps, or cervix being closed, or waiting for surgery?
 
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Anon_6061 replied to some_inquiz's response:
I know someone who recently went through this. Her doctor couldn't do an endometrial biopsy because of a stenotic cervix. She was told that she could be put under to dilate the cervix to be able to do the biopsy. Was that offered to you?

I had a hysterectomy and regret it every day. Hysterectomy is the most overused surgery after c-section. Only about 2% are done for cancer.

The uterus is generally treated as if it's useless after childbearing; however, it has a number of non-reproductive functions including pelvic integrity.

Have you looked into a pessary versus surgery for the prolapse? If you end up having surgery to suspend your bladder, it would seem reasonable to suspend your uterus at the same time versus removing it.
 
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Mary Jane Minkin, MD replied to some_inquiz's response:
Dear some_inquiz,
Indeed the thickening of the uterine lining and polyps could be related to the tamoxifen (although they certainly can happen to women who have never taken tamoxifen).
I don't know if you've read some of my earlier posts on the cervical stenosis. One medication that can be helpful to help dilate the cervix is misoprostol , which is actually a stomach ulcer drug! but it helps to dilate the cervix, too-you can take a pill by mouth; or some docs have you place it in the vagina. I have folks do it daily for a couple of days before trying a biopsy; and it does tend to help (and makes some women "biopsiable" when they weren't before.
And indeed, you may want to consider a pessary; pessaries can really help pelvic floor discomfort. It's worth considering to see how you would feel with one.
Good luck,
Mary Jane
 
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Dignity replied to Mary Jane Minkin, MD's response:
Dr. Minkin,

I am 65 and have been on bio-idential progesterone and Estrogin for 2 years. In 2/2013 I started the T.S. Wiley bioidenticals. In 4 weeks, I started with cramps and in 7 weeks the cramps became unbearable. My Ob-Gyn said my cervix was shut tight and found a large blood clot through an ultrasound. April 2013 she did a D And C.and there was no cancer. I had a normal pap smear October 2012 and the day before my surgary, my cervix opened and a lot of blood clots came out.

I am scheduled to have another ultrasound in two weeks to make sure my cervix is still open before I start bio-identicals again. Will bio-identical estrogen keep my cervix open? I don't want to cause another blood clot because my cervix won't allow menstruation. I am taking bio-identicals because they reversed my osteoposis and allowed me to sleep. I also suffer from urine leakage. Is there anything that can be done to keep my cervix open?
 
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Mary Jane Minkin, MD replied to Dignity's response:
Dear Dignity,
In general, women on estrogen tend to have less cervical stenosis; but even women on estrogen can develop cervical stenosis. A couple of thoughts; you may want to see your gynecologist more often than once a year; she can then more regularly check to see if your cervix is open, and stretch it a bit at your exam to keep it open. If it seems to be shut, we often will recommend a medication call misoprostol, which is used to treat ulcers, believe it or not; but it can help open the cervix, before say doing a biopsy. I don't usually recommend taking it on a regular basis; but you might want to take some before seeing your gynecologist, to check on your cervix.
Good luck,
Mary Jane
 
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Anon_6061 replied to Dignity's response:
Dignity - You said you started the Wiley protocol in February. Are you still on that? I know some women who were on it and it caused a lot of problems. They became overdosed with progesterone because it built up in their dermal tissues but it didn't adequately protect their uterine lining (topical progesterone usually isn't adequate to protect the lining). Also, the doses of estrogen and progesterone on Wiley are excessive. And the "inventor" Wiley isn't even a medical doctor.
 
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An_254057 replied to Mary Jane Minkin, MD's response:
Hi, I am 59 and just had an "attempted" painful cervical pap smear. I use vaginal estrogen weekly and used Misoprostol prior to my exam to "soften" the cervix. However, none of that was helpful. The doctor tried using cervical dilators, as she has done at previous exams. This time, the cervix is severely stenosed.
My particular dilemma is this: I am a DES daughter with a higher than normal risk of CCA of the cervix. I have been going for annual colposcopies since my early 20's with several biopsies (all normal) and one episode of dysplasia with no atypia. The option of not having pap smears of the cervical Os may not be an option for me.
The options that I have been given are: hysterectomy or annual paps using Misoprostol plus general anesthesia. I feel like both options are overkill.
I would appreciate your advice or direction to a DES specialist in the Boston area who may be able to add some specific expertise to this situation.
Thanks for your help.
 
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Mary Jane Minkin, MD replied to An_254057's response:
Dear An_254057,
This is a good question. I would agree that both options would sound like overkill, minus the DES question. I do think a consultation with a gynecological oncologist would be a very reasonable thought, to get another opinion on this. Fortunately, in Boston you have access to excellent gyn oncologists; Dana Farber, Brigham and Women's, and Mass General all have a tradition of strong gyn oncology, and the specialists at those programs would be able to give you a reasonable risk assessment. As DES use was actually fairly prevalent in the Boston area 50-60 years ago, they should be well familiar with the issues involved.
Good luck,
Mary Jane
 
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An_254380 replied to Mary Jane Minkin, MD's response:
Dear doctor Mary Jane Minkin, MD
My mother is 78 years old. Approximately 5 weeks ago she experienced a heavy bleeding we believed it was with urine with minor pain at lower area of the stomach, and we went to the emergency department at Saint John's Medical Health Center in Santa Monica, CA close from where she lives. They performed tests, including cat-scan and ultrasound, after which was determent that the blood is coming from vagina and found abnormality with a thicken wall in uterus, endometrial thickness 14mm with fluid overall. Next day per given instructions we went to see my mother's Gynecologist. The doctor performed another ultrasound and observed a few polyps inside her uterus, after that he referred us to the Gynecologic Oncology Specialist at Cedars-Sinai Medical Center / Samuel Oschin Cancer Institute in Los Angeles. During our initial visit with the specialist, she tried to scrub a sample manually to be sent to the lab to determent if it is cancerous. The doctor was not able to reach there (it was closed off of the opening) After the initial manual attempt, the doctor scheduled a surgical procedure, which required preparation and anesthesia to do the required biopsy test within surgical operation room environment. The doctor tried to perform the procedure yesterday, but she said she could not reach inside as the cervix is totally closed. In response to my question, the doctor said that the medication to force the opening would cause major negative side-affects, so she did not even consider it. Now she recommends hysterectomy to remove the Uterus"026 and claims that my mother should be able to survive such operation with the full anesthesia"026
Currently within last 3-4 weeks my mother has very small amount of bleeding with occasional day or two without any bleeding and no pain complains. Her general health condition is weak due to her age and overweight, she takes a lot of oral medications from blood-sugar diabetics and high blood pressure, she is not very mobile in daily movements and has Arthritis (periodic inflammation in joints), but her heart condition appears to be reasonably OK for the surgery according to her primary doctor"026 Psychologically my mother is optimistic. The Gynecologic Oncology Doctor-Specialist says that my mother has 20%-25% chance of having cancer"026
My family and I are very concern and don't know what to do"026 She may not survive the full anesthesia"026, and I worry about the recovery process even if the surgery goes well. I also feel that it may be not really 100% justifiable or necessary to go thru with such serious surgery, taking in consideration her current symptoms, age, health condition, and level of risk. I need my mother to stay with us longer, not just for me, but also for my mentally disabled brother and other close family. Please, give us your best advice and possibly recommend a good specialist for the second opinion.
Thank You very much,
YSB


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